Interruptions in Insurance More Frequent But Shorter

Action Points

Explain to interested patients that health insurance coverage is not continuous for everyone, as people move or lose or change jobs.

Note that the patterns of these interruptions in coverage have not been well studied.

Explain that this study did not address health outcomes, nor did it account for underinsurance.

WHEELING, W.Va., April 22 -- More Americans are experiencing periods in which they don't have health insurance than in the mid-1980s, but the interruptions have become shorter, researchers said.

Census Bureau data indicate that 21.8% of the population went without insurance at some point during a given 12-month period between 2001 and 2004, compared with 19.8% from 1983 to 1986 (P=0.04), reported David M. Cutler, Ph.D., of Harvard University, and Alexander M. Gelber, Ph.D., of the National Bureau of Economic Research, both in Cambridge, Mass.

But among individuals who lost insurance, more regained insurance within two years during the more recent period (79.7% versus 73.8%), the researchers said in the April 23 issue of the New England Journal of Medicine.

"Uninsured periods are more prevalent, but shorter, now than they were two decades ago," Drs. Cutler and Gelber wrote.

They also found that public insurance became a more important safety net as time went on.

Whereas from 1983 to 1986 only 8.7% of persons with no insurance transitioned to public coverage, the figure rose to 20.4% from 2001 to 2004 (P<0.001).

Still, most people who regained health insurance after an interruption did so with private coverage (65.2% from 1983 to 1986, 59.2% from 2001 to 2004).

Drs. Cutler (an adviser to President Barack Obama during the election campaign) and Gelber noted that patterns of health insurance interruptions over time have not been well studied.

They analyzed data from the Census Bureau's Survey of Income and Program Participation. The two study intervals were chosen because they were both periods in which the general economy was recovering from recession, although the later period was somewhat more prosperous.

Survey responses from 25,946 in the first period and 40,282 in the second period were included. The respondents were representative of the general population in major demographics such as age, sex, race, and education.

During both periods, the average percentage that was uninsured in any given month barely differed (15.8% versus 15.9%) and the percentage reporting fair or poor health was identical at 10.6%.

But significantly more were without insurance at some point during the later period (37.3% versus 35.4% during 1983 to 1986, P<0.001).

In addition, the more recent period, compared with the mid-1980s, was marked by a sharp increase in the likelihood that people without high-school education would lose insurance (40.3% versus 32.0%, P<0.001).

The researchers said the finding "parallels and reinforces the economy-wide increase in income-inequality during this time."

Those reporting fair or poor health were more likely to lose insurance during the later period (30.5% versus 19.3%, P<0.001) as well.

Median or mean duration of interrupted coverage was not reported.

Long interruptions in health coverage became less common, though. During 2001 to 2004, 20.3% of uninsured periods lasted more than two years, compared with 26.2% from 1983 to 1986 (P<0.05).

It also became somewhat easier for those in fair to poor health to regain insurance as time went on, though more frequently through public rather than private insurance, Drs. Cutler and Gelber found.

Somewhat surprisingly, the study showed that changes in job duration do not explain the findings on insurance interruption. The decline in duration of insurance interruptions remained unchanged even after Drs. Cutler and Gelber adjusted for employment status, they said.

Likewise, the probabilities of losing insurance remained the same in models that adjusted for employment status compared with unadjusted data.

The study was limited by the possibility of reporting bias during the survey periods, different weights used for each survey period, and absence of correlation with health outcomes. The issue of underinsurance was also not addressed.

The researchers credited the Medicaid program with shortening interruptions in coverage.

"It is possible that increased Medicaid coverage could also be partly responsible for the relatively large decrease in private coverage, if increased eligibility for public coverage led to an increased number of people who no longer had private coverage," they added.

"Serious problems could lie ahead if employer-based coverage continues to decline while the availability of public coverage remains the same or is reduced," Drs. Cutler and Gelber concluded.

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